Failure to Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to implement policies and procedures to ensure that each resident is offered the COVID-19 vaccine when available. Specifically, the facility did not offer the 2024-2025 Spikevax COVID-19 vaccine to Resident 2 or their representative, despite the vaccine being available from the facility's pharmaceutical provider. The facility's policy required that educational information and consents be completed for each dose administered, and documentation of vaccination acceptance or refusal be maintained. However, there was no documentation in Resident 2's clinical record indicating communication about the availability of the new vaccine or any offer made to the resident or their representative. Resident 2 had a medical history that included chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). The resident's immunization documentation showed that the last COVID-19 vaccination was administered in February 2024. Unfortunately, Resident 2 contracted COVID-19 in December 2024 and passed away in January 2025. An interview with the Director of Nursing revealed that the facility did not offer the vaccine to Resident 2 due to a lack of interest from residents or staff, which led to the decision not to order the vaccine from the pharmacy to avoid cost and waste.
Plan Of Correction
1. Facility cannot retroactively correct this concern for R2. 2. The facility will complete an audit of residents who have not received this season's Covid-19 vaccine and offer accordingly. 3. Re-education will be completed with licensed nursing staff to ensure residents are offered this at admission and then annually. 4. DON/designee will audit new admits x 2 months for offering of Covid-19 vaccine to ensure those who consented will receive the vaccine. Audits will be reviewed at QAPI for compliance and quality assurance.